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Vitamin D and Calcium
Evidence Reports/Technology Assessments, No. 183
Investigators: Mei Chung, MPH, Ethan M Balk, MD, MPH, Michael Brendel, BA, Stanley Ip, MD, Joseph Lau, MD, Jounghee Lee, PhD, Alice Lichtenstein, DSc, Kamal Patel, MBA, MPH, Gowri Raman, MD, Athina Tatsioni, MD, PhD, Teruhiko Terasawa, MD, and Thomas A Trikalinos, MD, PhD.
Structured Abstract
Background:
Since the 1997 Dietary Reference Intake (DRI) values for vitamin D and calcium were established new data have become available on their relationship, both individually and combined, to a wide range of health outcomes. The Institute of Medicine/Food and Nutrition Board has constituted a DRI committee to undertake a review of the evidence and potential revision of the current DRI values for these nutrients. To support this review, several US and Canadian federal government agencies commissioned a systematic review of the scientific literature for use during the deliberations by the committee. The intent of providing a systematic review to the committee is to support transparency of the literature review process and provide a foundation for subsequent reviews of the nutrients.
Purpose:
To systematically summarize the evidence on the relationship between vitamin D, calcium, and a combination of both nutrients on a wide range of health outcomes as identified by the IOM, AHRQ and technical expert panel convened to support the project.
Data sources:
MEDLINE; Cochrane Central; Cochrane Database of Systematic Reviews; and the Health Technology Assessments; search limited to English-language articles in humans.
Study selection:
Primary interventional or observational studies that reported outcomes of interest in human subjects in relation to vitamin D and/or calcium, as well as systematic reviews that met the inclusion and exclusion criteria. Cross sectional and retrospective case-control studies were excluded.
Data extraction:
A standardized protocol with predefined criteria was used to extract details on study design, interventions, outcomes, and study quality.
Data synthesis:
We summarized 165 primary articles and 11 systematic reviews that incorporated over 200 additional primary articles. Available evidence focused mainly on bone health, cardiovascular diseases or cancer outcomes. For many outcomes, it was difficult to draw firm conclusions on the basis of the available literature concerning the association of either serum 25(OH)D concentration or calcium intake, or the combination of both nutrients. Findings were inconsistent across studies for colorectal and prostate cancer, and pregnancy-related outcomes including preeclampsia. There were few studies for pancreatic cancer and immune function. Among trials of hypertensive adults, calcium supplementation lowered systolic, but not diastolic, blood pressure by 2–4 mm Hg. For body weight, the trials were consistent in finding no significant effect of increased calcium intake on weight. For growth rates, a meta-analysis did not find a significant effect on weight or height gain attributable to calcium supplement in children. For bone health, one systematic review found that vitamin D plus calcium supplementation resulted in small increases in BMD of the spine and other areas in postmenopausal women. For breast cancer, calcium intakes in premenopausal women were associated with a decreased risk. For prostate cancer, some studies reported that high calcium intakes were associated with an increased risk.
Limitations:
Studies on vitamin D and calcium were not specifically targeted at life stages (except for pregnant and postmenopausal women) specified for the determination of DRI. There is large variation on the methodological quality of studies examined. Use of existing systematic reviews limits analyses that could be performed on this source of information.
Conclusions:
The majority of the findings concerning vitamin D, calcium, or a combination of both nutrients on the different health outcomes were inconsistent. Synthesizing a dose-response relation between intake of either vitamin D, calcium, or both nutrients and health outcomes in this heterogeneous body of literature prove challenging.
Contents
- Preface
- Acknowledgments
- 1. Introduction
- 2. Methods
- Overview
- Development of the Analytic Framework and Refinement of Key Questions
- Definitions
- Key Questions
- Literature Search Strategy
- Study Selection
- Data Analysis
- Meta-analysis
- Grading of Studies Analyzed in This Evidence Report
- Critical Appraisal and Grading of Primary Studies
- Critical Appraisal of Systematic Reviews
- Reporting of the Evidence
- 3. Results
- Literature Search Results
- Vitamin D and Health Outcomes
- Calcium and Health Outcomes
- Combined Vitamin D and Calcium and Health Outcomes
- How does dietary intake of vitamin D from fortified foods and vitamin D supplementation affect serum 25(OH)D concentrations (arrow 4)?
- Outcomes for Tolerable Upper Intake Levels
- 4. Discussion
- Reference
- Abbreviations
- Latitudes of Selected Cities
- Appendixes
- Appendix A Search strategy for primary studies
- Appendix B Search strategy for systematic reviews
- Appendix C Evidence Tables: A-E
- Appendix C Evidence Tables: F-K
- Appendix C Evidence Tables: L-Q
- Appendix C Evidence Tables: R-Z
- Appendix D Evaluation of existing systematic reviews and evidence tables of the qualified systematic reviews
- Appendix E Blank Data Extraction Form and Quality Assessment Checklists
- Appendix F Excluded Studies
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.1 Contract No. HHSA 290-2007-10055-I, Task Order No. 4. Prepared by: Tufts Evidence-based Practice Center, Boston, MA.
Suggested citation:
Chung M, Balk EM, Brendel M, Ip S, Lau J, Lee J, Lichtenstein A, Patel K, Raman G, Tatsioni A, Terasawa T, Trikalinos TA. Vitamin D and Calcium: A Systematic Review of Health Outcomes. Evidence Report No. 183. (Prepared by the Tufts Evidence-based Practice Center under Contract No. HHSA 290-2007-10055-I.) AHRQ Publication No. 09-E015. Rockville, MD: Agency for Healthcare Research and Quality. August, 2009.
This report is based on research conducted by the Tufts Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA 290-2007-10055-I). The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.
This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850. www
.ahrq.gov
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